VAAGDEVI PHARMACY COLLEGE

CASE TITLE : RHEUMATOID ARTHRITIS

By :
SAI CHARAN
20ED1T0014
 INTRODUCTION:
RA is the most common form of autoimmune arthritis, About 75 percentage of RA Patients are women.
The disease most often begins between the ages of 30 and 50.However RA can occur at any age
RA is a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints.
Small joints in the hands and feet are most commonly affected. Sometimes RA can affect other organs, such
as eyes, skin or lungs
The joint stiffness in RA is often worst in morning .it may last one to two hours .
stiffness for a long time in the morning is a clue that you may have RA .as this is not common
in other conditions like for a instance, osteoarthritis ,arthritis ,SLE’s etc.
Other signs and symptoms that can occur in RA include:
Low grade fevers
Anorexia
Fatigue
loss of appetite
firm lumps called rheumatoid nodules, which grow beneath the skin in places such as elbow and hands
 DEFINATION :

 Rheumatoid arthritis is a chronic condition , in which is characterized by pain , swelling in

joints ,joint stiffness leading to a joint dysfunction and joint disability

Epidemiology :

 In US RA affects more than 1.3 million people

 About 75% of RA patients are women than men
 Studies revealed that women who smoked for >20years had 49% increased risk for RA and Seropostive
Rheumatoid arthritis.
 Thereby women are more prone to Rheumatoid arthritis than men
 Etiology :
o RA oftenly caused by several riskfactors includes
o AGE
o DIET :
o some evidences shown that high consumption of Red meat and Vitamin C may increase the risk of
devolping Rheumatoid Arthritis
o GENETICAL FACRORS :
variations or mutations of Human leukocyte antigen (HLA) DR-4 gene
o ENVIRONMENTAL FACTORS :
Smoking is the primary environmental risk factor of RA ,
it triggers the RA Specific immune reactions which ultimately contribute to RA
other combordities conditions occurs along with RA :
In case of EYES :
Inflammation of eyes can lead to scleritis which cause pain and redness of eye
HEART :
Inflammation of heart tissue called Pericarditis which causes Chestpain

LUNGS :
Inflammtion of pleural cavity of lungs called pleuritis

BLOOD VESSELS :
Inflammation in blood vessels known as Vasculitis

OSTEOPOROSIS :

SPLENOMEGALY :

MALIGNANCIES LIKE :
Leukemia's
Lymphomas
Prostate and cervix cancer which rarely seen
 PATHOPHYSIOLOGY:

These Two conditions are prone to rheumatoid arthritis are :

ACTIVATION OF T LYMPHOCYTES
FORMATION OF PANNUS
ACTIVATION OF T LYMPHOCYTES :
RA triggers the Activation of T lymphocytes

releases the inflammatory mediators like macrophages, monocytes and cytokines which regulates

Release of INF CYTOKINES

PRO INF CYTOKINES ANTI INF CYTOKINES

Releases IL-1,IL-6 and TNF alpha Releases IL-4 and IL-10

Increase in pro inf cytokines and decrease in anti inf cytokines ,imbalance leads to excessive inflammation

Activation of B lymphocytes

Rheumatoid factor Anti citriculated protien antibody (ACPA)

causes RA symptoms
FORMATION OF PANNUS :

Proliferation of INF CYTOKINES into Synorium

Enlargement of membrane to give space for inf cytokines in synorium

(formation of paanus )

To these paanus IGG antibodies entered leads to

Increase in INF cytokines causes imbalances between pro and anti inf cytokines

Releases enzymes which causes destruction of synovial joints

Cause RA symptoms
FERENTIAL DIAGNOSIS :
Patient may experience these RA symptoms associated with other conditions as :

Osteoarthritis

Psoriatic arthritis

Stensoing tenosynovitis

Carpel tunnel syndrome

Polymyalgia Rheumatica

Fibromyalgia

Hypermobility syndrome

Systemic lupus erythematosus

Paraneoplastic syndromes
GNOSTIC PARAMETERS :

LAB PARAMETERS :
CBC
ESR
CRP
RBS
Sr Creatinine
Spinal fluid analysis

RADIOGRAPHS :

X ray
MRI
Ultrasonography

IMMUNOLOGIC PARAMETERS :

Rheumatoid factor
Anti CCP (anti citriculated antibody)
ACPA (anti citriculated antibody )
MANAGEMENT :
Goals of treatment :

To reduce pain
To reserve joint function
To increase range of motion of joint (ROM)

Non – pharmacological therapy :

Maintain good diet

Reduce salt intake
Consumption of leafy vegetables ,fruits,legumes,nuts,beans,cerals,grains.
Unsaturated fats like olive oil.
IFE STYLE MODIFICATIONS :

 Reduce intake of salt

 Limit redmeat intake
 Avoid consumption of tobaco and smoking
 Physical exercises (to increase ROA )
 Consumption of anti inf foods like ginger,corriander,garlic etc
 PHARMCOLOGICAL TREATMENT :

• Pharmcological treatment of RA involves using of these class of drugs include :

• DMARDS
A Non biological DMARDS
B Biological DMARDS

CORTICOSTERIODS

NSAIDS

IMMUNOSUPRESSIVE AGENTS
IMMUNOSUPRESSIVE AGENTS :
1.T CYCLOSPORINE :
It is a immunomodulator or calcineurin inhibitor given at dose of 25-50mg once in a day per oral
MOA : IT is a calcineurin inhibitor , supress the T cell activation and differentiation (cause inflammation ) by inhibiting
synthesis of cytokines or inter leukins
INDICATION : RA , Psoriasis , bronchitis , organ rejections.
Adverse effects : tremors , HTN , nephrotoxicity , diarrhea

2.T AZATHIOPRINE :
It is a immunomodulator given at the dose of 50-75mg once a day per orally
MOA : it interferes with the cellular metabolism and inhibit the Dna and protien synthesis
INDICATION : RA , SLE’s , Crohn disease , ulcerative colitis
Adverse effects : leukopenia , lymphomas
DMARDS:
Non – Biological Dmards :
1.T METHOTREXATE :
It is called gold standard drug ,used in first line treatment of RA given per oral at dose of 7.5 – 10mg once in a day for a week .
MOA : it inhibits Dihydrofolic acid reductase which is responsible for the synthesis of Folic acid
helps in DNA synthesis
INDICATION :Rheumatoid arthritis , Psoriasis , myasthesia gravis , SLE’s , breast cancers
Adeverse effects :anemia,anorexia,nausea and vomit,renal failure ,leukopenia

2.T HYDROXY CHLOROUINE SULFATE :

It is a anti malarial drug ,given per oral at the dose of 200mg once a day for a week
MOA : exact mechanism is unkown but work as a anti inflammatory and immuno modulatory .
INDICATION : rheumatoid arthritis , malaria , SLE’s .
Adverse effects : retinotoxicity , skin rashes and itching ,
3.T LEFLUNOMIDE :
It is a immunosuppresive agent given per oral at the dose of 10-20mg thrice in a day
MOA : exact moa is unkown but inhibits T cell proliferation , therby decrease in B cell antibodies which prevents paanus
formation in RA
INDICATION : Rheumatoid arthritis
Adverse effects : diarrhea , HTN , nausea

4.SULFASALAZINE :
It is a immuno suppresive drug given per orally at the dose of 500mg twice a day
MOA : unkown moa but it has anti inflammatory properties which inhibits leukotriene synthesis ..
INDICATION : Rheumatoid arthritis , crohns diesase , ulcerative colitis
Adverse reactions : nausea vomiting , gastric distress , anorexia , headache
BIOLOGICAL DMARDS :

1.TNF APLHA ANTAGONISTS :

MOA : binds to tnf receptors and inhibit there actvity therby preventing synvovial inflammation .
Drugs include
a) Inj Etanercept
dose; 50mg SC once weekly
adverse effects : hypersenstivity reactions , upper respiratory tract infection , diarrhea
b)Inj Infliximab
It is tnf inhibitors given at the
dose of 3-5mg/kg iv for 3-6weeks
c)Inj adalimumab
Dose : 40mg SC once a weekly
d) Inj Golimumab
Dose : 50mg SC once a weekly
e) Cetrolizumab
Dose : 400mg SC once
2. IL – 2 Blockers :
inj Anakinra
Dose : given 100mg subcutaneously once a day
Side effects : nausea epigastric distress

3.IL – 6 BLOCKERS :
Inj Tocilizumab
Dose : given 160mg SC once
Side effect : anaphlayctic reactions ,nausea

3.T&B LYMPHOCYTE BLOCKERS :

a) T Rituximab 100-200mg
MOA : it inhibits the CD20 antigen actvity by cytolyisis
Adverse effects : fever , chills , pruritis
b) Inj Abatocept 125mg SC
MOA : t cell inhibitor
Adverse effects : fever , rashes , hypersenstivity reactions
Corticosteriods :

MOA : corticosteriods may inhibit the release of archadonic acid from the phospholipids therby reducing the formation of
prostaglandlin which cause inflammation

T Prednisolone : 5-7.5mg PO OD
Methyl prednisolone : 5mg PO OD
Beflazocort : 6-28mg PO OD
Triam citholone 40-120mg po OD

Adverse effects : edemas , pyscological effects like mood swings , confusions ,high blood pressure ,gastric problems
Non steroidal anti inflammatory drugs (NSAIDS) :

MOA : the main mechanism of action of nsaids are the inhibition of cyclooxygenase(COX) enzyme
Cox is required to convert archidonic acid into prostaglandlins which cause the inflammation
Drugs include
a) Ibuprofen : 400-800mg QID PO
b) Naproxen : 500 mg BD PO
c) Mefanamic acid : 500mg QID PO
d) Diclofenac sodium : 100mg OD PO

e) COXIBS LIKE
Celecoxib : 200mg BD PO
Etericoxib : 60-120mg OD PO
Etodolac : 300-600mg OD PO
CASE PROFILE :
SUBJECTIVE FINDINGS :
A 50 yrs male patient came to the hospital and admitted in rheumatology department
with chief complaints of joint pains and swelling in small joint fingers - since 6months
morning stiffness in joints and toes about 2hours and pain in lumbar region with difficulty in standing
PAST MEDICAL HISTORY :
No H/O DM /HTN/TB/CVA/CAD
FAMILY HISTORY :Nothing significant
Mixed diet
Non smoker , alcohol occassionaly and regular bowel habits ,no previous allergies
PHYSICAL EXAMINATION :
Patient is conscious and coherent
Diffused swelling present in all small inter-phalangeal and meta-carpophalangeal joints with redness of skin
GENERAL EXAMINATION :
Temp :Afebrile
BP :130/80mm hg
Pulse : 80bpm
SYSTEMIC EXSMINATION : CVS –s1 s2 + and P/A – soft
Provisional diagnosis : Polyarthritis

LAB FINDINGS :
1.CBC – Hb : 13.0 (13-17gm%)
2.Serum uric acid – 6.10 (3.4-7.0mg%)
3.Calcium -8.3 (8-10mg/dl)
4.CRP – 11.7mgm/l (0.0-6mgm/L)
5.RA Factor – 18.40IU/mL (<14Iu/mL )
6.ESR – 49 1st hour (0-9/1 st hour )
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OBJECTIVE FINDINGS :
DAY 1 DAY 2 DAY 3 DAY 4

PATIENT C/C C/C C/C C/C

TEMPERATURE FEBRILE FEBRILE AFEBRILE AFEBRILE

BP 120/80mmhg 120/80mmhg 110/70mmhg 110/60mmhg

PR 80bpm 80bpm 72bpm 74bpm

CVS

RESP BAE + BAE + BAE + BAE +

P/A Rebound Tenderness + Soft Soft

Tenderness +
LABORATORY INVESTIGATIONS :

 Hb – 13.7g%  Serum electrolytes :

 RBC – 4.5 millioncells Na+ - 140.3
 WBC – 10,500/cmm K+ - 3.9
• N - 63%  Blood urea – 23.4
• L - 20%  Sr.creatinine – 1.1
• M - 13%  BT - 2′ 40″
• E - 4%  CT - 4′ 10″
• B – 0%  HIV – non – reactive
 PLATELETS – 1.16 lacs  Hbs Ag : -ve
 SURGERY ON 17/11/21
PAIN SCORE :
M-0
A -1
N -1
T -0
R - 1 SCORE – 6/10
E - 1
L - 2
S -0
 SCANS :
o USG Abdomen :-
A blind ending tubular structure noted m/s 9.6 mm in diameter ,
non-compressible, non-peristaltic with surrounding fat strands .
 ASSESSMENT :
By the above subjective findings and objective findings ,the patient was diagnosed as
ACUTE APPENDICITIS .
PLAN :
DRUG GENERIC NAME DOSE ROA FRQY DAY 1 DAY 2 DAY 3 DAY 4

IVF 1DNS - - iv ● ●
1RL
Inj.monocef Ceftriaxone 1g iv BID ● ● ● ●

Inj.metrogyl metronidazole 500mg iv TID ● ● ● ●

Inj.amikacin Amikacin 500mg iv BID ● ● ● ●

Inj.pantop Pantaprazole 40mg iv BID ● ● ● ●

Inj.diclo Diclofenac 75mg im BID ● ●

Tab MVT - - po OD ● ●

Tab Vit C Ascorbic acid - po OD ● ●

 PATIENT COUNSELLING :
• Take the medicines in time and with the right dose .
• Instruct the patient to eat nutritious food such as vegetables and fruits .
• Limit the consumption of fatty foods.
 LIFE STYLE MODIFICATIONS :
• Take a high fibre diet -whole grains, fruits, and vegetables, beans and legumes, nuts, and seeds.
• Maintain Balanced diet
• Take vitamin supplements
• Perform exercise as suggested by the physicisan
• Improve your posture